Strep strikes rapidly following minor scratch
First report of transmission due to needlestick
A 27-year-old resident at a Texas medical school has survived a life-threatening case of necrotizing fasciitis after acquiring what appears to be the first documented transmission of Group A streptococcus via needlestick.
As recently reported by Carin Hagberg, MD, assistant professor of medicine in the department of anesthesiology at the University of Texas Medical School in Houston, the case involved a strep infection that proceeded with striking rapidity after only a superficial scratch.1 The resident was injured while inserting a central venous catheter into a patient newly admitted to the hospital with sepsis of unknown origin.
"The patient’s blood was on the needle," Hagberg tells Hospital Infection Control. "She was scratched by the needle, and she got it. This was just a very superficial scratch. It was not a puncture wound needlestick."
The index patient died 12 hours after admission from Group A streptococcus sepsis.
"After the patient died of Group A strep, [clinicians] presumed that [the resident] might have been exposed to it because she had fever, chills, erythema, induration, and pain in her left hand," Hagberg says. "That was all within 14 hours."
During the ensuing 48 hours, leukocytosis developed in the resident, followed by leukopenia, a prolonged prothrombin time and partial-thromboplastin time, decreased hemoglobin level and platelet count, hypotension, and progression of the area of induration and erythema toward her elbow and axilla, Hagberg and colleagues reported. A diagnosis of necrotizing fasciitis due to Group A streptococcus was made. Surgical debridement of the region of cellulitis revealed necrosis of subcutaneous tissue, fascia, and muscle. As the patient improved, the wound defect was closed with a muscle flap, and she was discharged 17 days after admission.
"She almost lost her arm, and if they didn’t do the surgical debridement she could have died," Hagberg says. "She’s back to work now. She’s got a pretty good-size flap on her arm, but she’s alive."
Though transmission of bacterial pathogens via blood exposures is uncommon, the case underscores that under such conditions, virulent bacteria like Group A strep can resemble a bloodborne virus. The index patient was highly infectious, presumably due to high titer of the bacteria in the blood, Hagberg notes.
"She got a good dose in that little scratch," she says. "It was just very striking to us. I’m an anesthesiologist and I stick people all the time. We’re always worried about the viral infections HIV and hepatitis. Now here comes another one that seems to appear just as deadly."
As the anesthesiologist during the surgical debridement of the infected resident, Hagberg double-gloved and exercised extreme caution in intubating and starting IVs during the procedure.
"It was very scary," she says. "Here she got it by putting in a central line in a patient, and we were putting a central line in her."
The only related report Hagberg and colleagues could find in the medical literature involved an emergency medical worker who was infected after attempting to resuscitate a child with strep infection.2 The worker a firefighter was apparently exposed after scraping one of his hands, which were covered with the child’s sputum. Two days later he was hospitalized with toxic shock syndrome, but eventually recovered. (See Hospital Infection Control, May 1992, pp. 57-61.)
Though no official recommendations are in place for administering postexposure prophylaxis for health care workers exposed to patients with Group A streptococcus, infection control professionals may want to consider the measure in cases of severe exposure, clinicians advise. (See related story in HIC, June 1997, pp. 89-90.) In the case in Texas, nafcillin therapy was begun after the patient suffered chills and fever. Penicillin G and clindamycin were added when it became known that the source patient had died of strep sepsis.
References
1. Hagberg C, Radulescu A, Rex JH. Necrotizing fasciitis due to Group A streptococcus after an accidental needle-stick injury. (Correspondence) N Engl J Med 1997; 337:1699.
2. Valenzuela TD, Hooton TM, Kaplan EL, et al. Transmission of toxic strep’ syndrome from an infected child to a firefighter during CPR. Ann Emerg Med 1991; 20:90-92.
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